The Department of Health Care Services (DHCS) Pharmacy Benefits Division (PBD) has introduced a new section in the Pharmacy Provider Manual. This section has been added to enable providers to more easily identify Physician Administered Drugs available through the Pharmacy Benefit.

This new section lists the drug products and units of measure for medications that are given/administered/implanted/inserted by physicians or other qualified medical practitioners and are available and billable as pharmacy benefits. Unless otherwise indicated, an approved Treatment Authorization Request (TAR) is required for reimbursement. Pharmacy claims in this section are billed using the product National Drug Code (NDC).

2. Phase 3: RTD Generation is Discontinued

The Department of Health Care Services (DHCS) has eliminated the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1). The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs were discontinued in multiple phases. The first phase was implemented in November 2017 and the second phase was implemented in February 2018. The third and final phase implemented in May 2018. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. The generation of RTDs has been completely discontinued and providers will no longer receive RTDs. Any current unprocessed RTDs in the providers possession may still be returned to the DHCS Fiscal Intermediary by the due date listed on the RTD and will be processed as normal.

Additional changes to the provider manual will be announced in a future monthly bulletin. Providers are encouraged to routinely check the Medi-Cal website for more information.

6. Update to Newborn Screening Rates

Effective for dates of service on or after July 1, 2018, the rate for HCPCS code S3620 (newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel) has been updated to $142.25.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

For more information, providers may refer to the Medi-Cal Rates web page on the Medi-Cal website.

7. CCS Service Code Groupings Update

The following codes will be added to the California Children's Services (CCS) Service Code Groupings (SCGs).

Added Codes:

Effective Date

Code

SCGs

August 1, 2017

CPT-4 codes 81430, 81431

04, 05

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

8. Pharmacist Furnishing of Medications under Statewide Protocol

All medications authorized by Senate Bill 493 and subsequent amendments of the Business and Professions Code (B&P Code), Section 4052 are reimbursable by the Medi-Cal program for pharmacy claims, including drug costs and dispensing fees, when furnished by pharmacists within their scope of practice. Pharmacists do not need to be enrolled as Ordering, Referring and Prescribing (ORP) providers when they are the prescriber on record using their own National Provider Identifier (NPI) for these claims.

The following medication classes are currently exempt from ORP enrollment for reimbursement of pharmacy claims, including drug costs and the dispensing fees, when furnished by pharmacists within their scope of practice:

Naloxone

Nicotine replacement therapy

Self-administered hormonal contraceptives

Travel medications

Vaccinations

When the Department of Health Care Services (DHCS) implements reimbursement for the professional services associated with furnishing the above medication classes, as authorized under Assembly Bill 1114 and Welfare and Institutions Code (W&I Code), Section 4132.968, the pharmacist providing such services must be an approved ORP provider. Additionally, all pharmacists furnishing medications under collaborative practice agreements according to B&P Code, Sections 4052.1, 4052.2 and 4052.6 will be required to be ORP providers in order for pharmacy claims to be reimbursed. Therefore, DHCS encourages all pharmacists to become ORP providers with the Medi-Cal program.

9. Medi-Cal List of Contract Drugs

A summary of drugs that have been changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Effective retroactively for dates of service on or after January 1, 2018, the rate for CPT-4 code 81519 (oncology [breast], mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as a recurrence score) is updated. An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims. No action is required of providers.

For a list of current rates, providers may refer to the Medi-Cal Rates page on the Medi-Cal website.

11. Medi-Cal Benefit Added: Nonmedical Transportation

Pursuant to Welfare and Institutions Code (W&I Code) Section 14132 (ad) (1), effective for dates of service on or after July 1, 2018, non-medical transportation (NMT) is covered, subject to utilization controls and permissible time and distance standards, for eligible full-scope Medi-Cal fee-for-service recipients beneficiaries and pregnant women during pregnancy and for 60 days postpartum, including any remaining days in the month in which the 60th postpartum day falls. NMT includes transporting recipients to and from Medi-Cal covered medical, mental health, substance abuse or dental services.

W&I Code 14132 (ad)(2)(A)(i) defines NMT as including, at minimum, round trip transportation for a recipient to obtain covered Medi-Cal services by passenger car, taxicab, or any other form of public or private conveyance.

NMT does not include the transportation of sick, injured, invalid, convalescent, infirm or otherwise incapacitated recipients by ambulances, litter vans or wheelchair vans licensed, operated and equipped in accordance with state and local statutes, ordinances or regulations, as these would be covered as non-emergency medical transportation (NEMT) services.

Registering NMT Vehicles and Enrolling as an NMT Provider
Based upon the authority granted to the director of the Department of Health Care Services (DHCS) in accordance with W&I Code Section 14132(ad)(8), the director is establishing Medi-Cal provider enrollment requirements for the provision of NMT services by currently enrolled Medi-Cal NEMT providers that request to provide NMT services by passenger vehicle and for enrolling transportation providers for NMT only. These requirements implement W&I Code, Sections 14043.15 and 14043.26 and as such have the full force and effect of law.

Effective June 15, 2018, transportation providers who are currently enrolled in Medi-Cal as NEMT providers and who wish to provide NMT services may request to become an NMT provider and provide NMT services, as defined by W&I Code, Sections 14132 (ad)(2)(i) and 14132 (ad)(2)(ii). Current NEMT providers must submit a completed Medi-Cal Supplemental Changes (DHCS 6209) form. NEMT providers requesting to add NMT services should state so in the space provided on page 16, items 37 and 38 of the DHCS 6209 form. NMT vehicles may be added on page 13; copies of the Department of Motor Vehicles (DMV) vehicle registration and proof of vehicle insurance must be included.

Only enrolled providers who have been approved by DHCS to render NMT services may bill for NMT. Providers approved by DHCS to also provide NMT services may begin rendering services to eligible fee-for-service recipients and billing DHCS for dates of service on or after July 1, 2018. The effective date of enrollment for approved NMT services will be retroactive to the date a complete application was submitted.

Effective retroactively for dates of service on or after June 1, 2017, the reimbursement rates for initial and periodic comprehensive medicine evaluation and management for recipients 18-39 years of age (CPT-4 codes 99385 and 99395) are established.

A list of current rates can be found on the Medi-Cal Rates page of the Medi-Cal website.

13. 2018 Rate Adjustment for Clinical Laboratory Services

Effective retroactively for dates of service on or after January 1, 2018, reimbursement rates for clinical laboratory services are adjusted. An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims. No action is required of providers. Providers may refer to the Medi-Cal Rates page of the Medi-Cal website for current reimbursement rates.

14. Rate Update for Certain Anesthesia Services

Effective retroactively for dates of service on or after January 1, 2018, rates for the following CPT-4 codes reimbursable for anesthesia services are updated. These codes are no longer reimbursable “By Report.”

Effective for dates of service on or after June 1, 2018, the following ICD-10-CM diagnosis codes are added to the list available for procedure codes related to genetic testing for Lynch syndrome. One diagnosis code is required.

C17.0 – C17.9

C65.1 – C66.9

C24.0 – C24.9

C71.0 – C71.9

C25.0 – C25.9

D23.0 – D23.9

Also effective for dates of service on or after June 1, 2018, the presence of synchronous, metachronous colorectal or other Lynch-associated tumors is added to the list of conditions for which services are reimbursable under CPT-4 code 81403 (molecular pathology procedure, Level 4) for Lynch syndrome testing. One of the allowable conditions must be included on a Treatment Authorization Request (TAR).

16. Reminder: VeriFone VX 520 POS Device to Decommission in July 2018

In July 2018, the VeriFone VX 520 Point of Service (POS) device will be decommissioned. Transactions from these devices will no longer be accepted or processed after decommission. A final notification letter will be mailed out instructing providers to return the devices. Providers may contact the POS Help Desk at 1-800-541-5555 (option 5, followed by option 6) for information about the decommission and to learn about available alternative options.

17. Provider Orientation

Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Provider Orientation training is delivered online and in person and includes information on comprehensive family planning, program benefits and services, client eligibility, provider responsibilities and compliance.

Each provider's service location is required to be certified for enrollment in the Family PACT Program. Applicants who are enrolled in Medi-Cal and in good standing or are pending Medi-Cal enrollment and who have submitted a Family PACT application packet may complete the Provider Orientation to certify a site for enrollment.

Each service location must designate one eligible representative to be the site certifier. The site certifier cannot certify multiple sites.

The medical director, physician, nurse practitioner or certified nurse midwife who is responsible for overseeing the family planning services rendered at the location to be enrolled is eligible to certify the site.

Provider Orientation details and registration information is posted on the Family PACT website at www.familypact.org.

18. July 2018 Medi-Cal Provider Seminar

The July Medi-Cal provider seminar is scheduled for July 17 – 18, 2018, at the Almansor Court in Alhambra, California. Providers can access a class schedule for the seminar by visiting the Provider Training web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the DHCS Fiscal Intermediary (FI) for Medi-Cal conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Changes to Medi-Cal billing

Basic and advanced billing issues

Provider-specific billing questions

Specialty programs such as Home Health Agencies (HHA), Home and Community-Based Services (HCBS), Hospice Care and Family Planning, Access, Care and Treatment (Family PACT) Program

Providers must register by July 3, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 3, 2018, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks page of the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative web page, enter the ZIP code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a representative.

Providers are encouraged to bookmark the Provider Training web page and refer to it often for current seminar information.

19. A New Way to Subscribe – Contact Medi-Cal Subscription Service Representatives

Medi-Cal is committed to keeping you up-to-date on the latest Medi-Cal news and policy updates.

The Medi-Cal Subscription Service (MCSS) is a free service that provides subscribers with personalized email notifications for urgent, high-impact announcements and monthly news/policy updates as they post to the Medi-Cal website.

Providers can now contact MCSS representatives directly at MCSSCalifornia@conduent.com to subscribe and for assistance with managing subscriptions. Subscribing is simple and free!

If you have not yet subscribed to MCSS, Medi-Cal encourages you to utilize one of the following two methods to subscribe.

20. Get the Latest Medi-Cal News: Subscribe to MCSS Today

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.